Santa ClaraCounty

Social Services Agency

Department of Family and Children’s Services

PRELIMINARY CERTIFICATION FOR FAMILY UNIFICATION

PROGRAM (FUP) VOUCHER ELIGIBILITY

Head of Household Name:
Address:
Telephone #:

The above named family has been preliminarily certified as eligible for the Family Unification Program. I have attached the supporting documentation verifying that the lack of adequate housing is a primary factor, among others, in:

The imminent placement of the family’s child(ren) into out-of-home care.

The delay in the discharge of the child(ren) to the family from out-of-home care.

Other risk factors for abuse/neglect of a child that exist are noted on reverse.

Chair, FUP Multidisciplinary Team (Print)SignatureDateTelephone
The lack of adequate housing means:
  1. Living in substandard or dilapidated housing; or
  2. Homeless; or
  3. Displaced by domestic violence; or
  4. Living in an overcrowded unit; or
  5. Living in housing not accessible to its disabled child(ren)/children due to the nature of the disability.
Substandard Housing is defined as housing that:
  1. Is dilapidated;
  2. Does not have operable indoor plumbing;
  3. Does not have a usable flush toilet inside the unit for the exclusive use of the family;
  4. Does not have electricity or has unsafe electrical service;
  5. Does not have a safe or adequate source of heat;
  6. Should, but does not have a kitchen; or
  7. Has been declared unfit for habitation by an agency or unit of government.
Homeless is defined as:
  1. Lacks a regular, fixed and adequate nighttime residence and has a primary nighttime residence that is:
  2. A supervised public or private operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing);
  3. An institution that provides temporary residence for persons intended to be institutionalized; or
  4. A public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.
Displaced by Domestic Violence is defined as:
  1. The applicant has vacated a housing unit because of domestic violence;
  2. The applicant lives in a housing unit with a person who engages in domestic violence;
  3. Domestic violence means felony or misdemeanor crimes of violence committed by a current of former spouse of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or who has cohabitated with the victim as a spouse, by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction receiving grant monies, or by any other person against an adult victim who is protected from that person’s acts under the domestic or family violence laws of the jurisdiction.
Living in Overcrowded Housing is defined as:
  1. The family is separated from its child (or children) and the parent(s) are living in an otherwise standard housing unit, but, after the family is re-united, the parents’ housing unit would be overcrowded (based on HACSC subsidy standards) for the entire family and would be considered substandard;
  2. The family is living with its child (or children) in a unit that is overcrowded (based on HACSC subsidy standards) for the entire family and this overcrowded condition may result in the imminent placement of its child (or children) in out-of-home care.

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File: 3rd Fastener, Left - Middle / Certification For FUP Voucher Eligibility – 2/11/10
cc. Housing Authority / Page 1 of 2

Protective[1] and Risk[2] Factors for Child Abuse and Neglect

(Check all factors that apply to the family’s circumstances)

Protective Factors:

Nurturing and attachment

Knowledge of parenting and of child and youth development

Parental resilience

Social connections

Concrete supports (basic needs are met)

Risk Factors:

Age 0-3

Physical, cognitive and/or emotional disabilities

Parent/Caregiver Factors:

History of abuse or neglect as a child

Substance abuse

Negative attitudes about child behavior and inaccurate knowledge of child development

Teen parent

Family Factors:

Single parent

Domestic Violence

Stressful life events (e.g., job loss, illness, death in family)

Environmental Factors

Poverty and unemployment

Social isolation, little social support

Violence in the community

Other Factor(s)

(Specify):

[1] Child Welfare Information Gateway

[2]A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice, What Factors Contribute to Child Abuse and Neglect? Children’s Bureau (HHS) User Manual Series (2003)